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Potpourri from Clinical Work IV

I was palliative care attending for a month, from mid-December to mid-January. Here a few observations from my time on service:

Holding on for the holidays. In mid-December the hospital was pretty quiet and the hospital half full. By the time I left in mid-January, the hospital, ICU, nursing home, and hospice unit were all full. I've heard of people "holding on for the holidays," but this was pretty impressive first hand experience. Does anyone know if this phenomena has been studied? Pretty impressive evidence of a mind-body connection.

Passing of the greatest generation. A 95 year old veteran I cared for described serving in General Patton's battalion in Europe. Patton planned to storm a village at night, and told the troops, "We will take that village tonight! I don't care how many dog tags we go through, we are going to take that village!" That was Patton. These are the last years we will care for these great veterans. Sad.

Vietnam veterans are dying. This is completely anecdotal, but I feel like as the Vietnam veterans are starting to die in higher numbers, we're seeing more diseases associated with alcohol and substance abuse, specifically, cirrhosis and head and neck cancer. Does anyone else feel this way?

Don't forget the bowel regimen. A resident I worked with said that the saying in her residency is "The hand that forgets to write the bowel regimen is the hand that disimpacts the patient." That will make you remember!

Palliative Care Consult. How do you respond when you get one of these palliative care consults? (If no video below, click here).

Sorry, got cut off. In response to your question about death postponement, I had heard that there was a literature on this - the study I recalled looked at deaths among Chinese around the new year holiday and found a positive effect.

However, this recent article from a quick pubmed search found no support. Oh well.

Great finds Chris. I'll try to trump you though. There is some evidence outside of medicine that death may be elastic (see our post from 1 year ago titled "Death and Taxes). Joel Slemrod and Wojciech Kopczuk won the IgNobel prize for work they did examining the timing of deaths in the period surrounding 13 major changes in the estate tax. The results, as noted in the previous post, show a significant "death elasticity" with the reported date of death responding significantly to changes in the estate tax. The conclusion - for individuals dying within two weeks of a tax reform, a $10,000 potential tax saving increases the probability of dying in the lower-tax regime by 1.6%.

Take home point - there may be some elasticity to the timing of ones death. I dont think taxes were the reason for what Alex saw though.

Thanks Chris and Eric. Your right Chris, should have made the palliative care doc the superhero!

Sort of sad that the literature suggests that people can hold on for taxes, but not the holidays.

As the WSJ article Eric cites points out, it may not be the patients making these decisions about holding on and letting go. Rather that families keep loved ones alive in the ICU for the tax benefits, but not for the birthdays and holidays.

Thank you for sharing your thoughts about caring for our Nation's real heroes...our Veterans. I'd like to point out that both the EPEC and ELNEC projects have partnered with VA Healthcare to update the curricula with veteran specific content regarding the unique needs of Veterans at end of life. This is very important work because more Veterans recieve healthcare outside of VA Healthcare than are enrolled in VA. Accordingly, we share the responsibility to honor and care for these heroes together. Please contact me if you'd like more information or to be in touch with your local VA Hospice and Palliative Care Program Manager or Clinical Champion. Thank you, again, for sharing your thoughts and recognizing the honor in caring for Veterans.

Palliative care docs aren't superheroes. Superheroes have a perpetual fear of death and a belief that they can save everyone and they do not accept things that they cannot change. Further, they lead double lives, work crazy hours, and neglect their families (or just don’t have them). Alex, perhaps subconsciously, I think you got it just right!!

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